Claims Review Analyst

EmblemHealth; New York (NY); On-site; USD 49,000 - 83,000; Full time

Job summary

EmblemHealth is seeking a claims analyst to support performance management and resolve complex claims disputes in a large health system environment.

The role requires 2–3 years of claims/billing experience, strong knowledge of coding and processing rules, and proficiency with MS Office. You’ll analyze trends, communicate findings, and drive workflow improvements across departments.

Qualifications

• Bachelor’s degree required.
• 2–3 years’ related work experience in professional/facility claims or benefits/billing environment required.
• Strong knowledge of claim processing policies and procedures required.
• Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures required.
• Proficiency with MS Office applications (word processing, database/spreadsheet, presentation) required.
• Ability to accurately interpret information from contractual and technical perspectives required.
• Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational improvement and efficiencies required.
• Strong analytical and problem-solving skills required.
• Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines required.
• Ability to effectively absorb and communicate information required.
• Strong Interpersonal and teamwork skills required.

Responsibilities

• Support contract performance management of a large health system.
• Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines.
• Identify and analyze single issues and trends to determine root causes.
• Provide recommendations for solutions to minimize errors and delays in systems and/or processes.
• Monitor system output to ensure proper functioning.
• Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.
• Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.
• Track issues and monitor trends to support their resolution.
• Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
• Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
• Conduct regular meetings with the assigned provider groups for status of AR files and recycles.
• Support departmental goals for cycle time by organizing and tracking claims for review.
• Monitor and provide timely responses for the designated provider group emails and AR files.
• Perform other related tasks as directed or required.

Skills

Claims knowledge

Medical coding

MS Office

Data interpretation

Analytical thinking

Multitasking

Teamwork

Education

Bachelor’s degree

Tools

MS Office

Job description

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com .

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• Support contract performance management of a large health system.
  
• Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines.
  
• Identify and analyze single issues and trends to determine root causes.
  
• Provide recommendations for solutions to minimize errors and delays in systems and/or processes.
  
• Monitor system output to ensure proper functioning.

Principal Accountabilities

• Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.
  
• Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.
  
• Track issues and monitor trends to support their resolution.
  
• Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
  
• Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
  
• Conduct regular meetings with the assigned provider groups for status of AR files and recycles
  
• Support departmental goals for cycle time by organizing and tracking claims for review.
  
• Monitor and provide timely responses for the designated provider group emails and AR files.
  
• Perform other related tasks as directed or required.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor’s degree required; additional experience/specialized training may be considered in lieu of education requirements

Relevant Work Experience, Knowledge, Skills, and Abilities

2 – 3 years’ prior related work experience in professional/facility claims or benefits/billing environment required

• Strong knowledge of claim processing policies and procedures required
  
• Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures required
  
• Proficiency with MS Office applications (word processing, database/spreadsheet, presentation) required
  
• Ability to accurately interpret information from contractual and technical perspectives required
  
• Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational improvement and efficiencies required
  
• Strong analytical and problem-solving skills required
  
• Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines required
  
• Ability to effectively absorb and communicate information required
  
• Strong Interpersonal and teamwork skills required

Additional Information

• Requisition ID: 1000003278
• Hiring Range: $48,600-$83,160

Security Disclosure

If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.

Pay Disclosure

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.

EEOC Statement

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

Sponsorship Statement

At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.